Klin Farmakol Farm. 2024;38(1):9-14 | DOI: 10.36290/far.2024.002

Errors occurring during nurse administration of medicines to hospitalized patients: an observational-interventional study

Kateřina Malá-Ládová¹, Josef Malý¹, Ondřej Tesař¹, Martin Doseděl¹, Iva Brabcová², Hana Hajduchová², Martin Červený², Radka Prokešová³, Ivana Chloubová², Jiří Vlček¹, Valerie Tóthová²

¹ Katedra sociální a klinické farmacie, Farmaceutická fakulta v Hradci Králové, Univerzita Karlova

² Ústav ošetřovatelství, porodní asistence a neodkladné péče, Zdravotně sociální fakulta, Jihočeská univerzita v Českých Budějovicích

³ Ústav humanitních studií v pomáhajících profesích, Zdravotně sociální fakulta, Jihočeská univerzita v Českých Budějovicích

Introduction: The medication administration to hospitalized patients is critical in the delivery of healthcare services and is associated with the occurrence of various categories of errors with real impact on patient health and healthcare costs.

Aim: The aim of this study was to analyse the impact of interventions and their sustainability on the prevalence of errors asso­ciated with medication administration by nurses to hospitalized patients.

Methods: Data were obtained from an observational intervention study conducted from 2020 to 2023 and analysing medication administration by nurses in one of the Czech hospitals. Data collection was done by direct passive observation by a team including a nurse and a pharmacist in the internal medicine, surgery, and long-term wards on three consecutive days during morning, midday, and evening administrations. All drugs administered at the time of observation, details of the patient, the nurse administering the medicine, the actual administration of the medicine, and the correct method of administration and handling of each dosage form were recorded. All data, including nurse data, were anonymised, and protected. After initial data collection, complex interventions were developed and implemented based on the data collected. Errors were divided into medication and process errors and the impact and sustainability of the proposed interventions were assessed using statistical methods.

Results: A total of 3 826 drugs administered by 55 nurses to 222 patients with a mean age over 75 years were observed. More than 80 % were solid oral dosage forms. The highest prevalence of errors was incorrect timing in relation to food, lack of patient identification, lack of nurse hand disinfection prior to medication administration, failure to check if patient used administered drug, failure to use clean equipment for medication administration. In all these cases, the proposed interventions proved to be effective, and a statistically significant improvement was observed over the course of the study.

Conclusion: The positive impact of the interventions on reducing the occurrence of medication errors in the administration of medicines by nurses shows that maintaining and further strengthening a safety culture in the delivery of healthcare in the hospital requires repeated education of healthcare workers.

Keywords: hospitalization, intervention, medication administration by a nurse medication error, safety culture.

Accepted: March 26, 2024; Published: April 8, 2024  Show citation